Race and the white coat

Racial bias in doctors and healthcare workers is doing great harm. Is enough being done to stop it?

By Rahul K. Parikh, M.D.

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Mignon Khargie / Salon

April 22, 2008 | Here's something the medical community has known for a long time: Minorities in this country, particularly African-Americans, are not as healthy as whites. They suffer from high rates of cardiovascular disease, diabetes, HIV, cancer, asthma and other chronic illnesses.

There are many reasons for the disparities. Blacks have less access to healthcare. Many lack health insurance altogether. A study in the New England Journal of Medicine showed that black communities have fewer primary care doctors, and that those doctors reported a harder time getting their patients quality services due to insurance restrictions.

When minorities get sick, they're likely to show up in an emergency room because they don't have anywhere else to go. When they get there, they're usually sicker because of the delay in seeking care. As the New England Journal study showed, minorities are more likely to get a doctor who isn't board certified and is of lower quality.

In 2002, the Institute of Medicine issued a sobering report about health disparities in America. In that report, the IOM challenged assumptions by asking one very hard question: Do doctors treat minority patients differently? Its answer, after reviewing more than 100 studies, was yes, "evidence suggests that bias, prejudice and stereotyping on the part of health care providers may contribute to differences in care."

Most of these studies adjusted for differences in incomes, age, insurance status and disease severity. In other words, the only factor that contributed to the disparity in treatment was the color of a patient's skin. Studies show that African-Americans in general harbor suspicion toward the medical community, a feeling that may lead some blacks to decline or refuse recommended treatments. But the IOM determined that this couldn't account for the severity of black-white disparities.

Over the past decade, there's been a growing body of evidence to support the IOM's conclusion. A 2000 study demonstrated that doctors rated black patients as less intelligent, less educated, more likely to abuse drugs and alcohol, more likely to fail to comply with medical advice, more likely to lack social support, and less likely to participate in cardiac rehabilitation than whites, even after income, education and personality characteristics were taken into account.

Researchers have also found that African-Americans with chronic renal failure are less likely than whites to be offered information and a referral for a kidney transplant. They've learned that blacks are regularly undertreated for pain from fractures and cancer, and are less likely to be prescribed appropriate medications for certain psychiatric problems.

Doctors are sworn by their oath and bound by law to treat patients equally. Most of us got into this business because we wanted to do right by people. Race, class and gender aren't supposed to influence us. But it would seem something is amiss when we treat black patients.

To figure out why, a group of Harvard Medical School researchers turned the spotlight on doctors. The researchers took a group of 287 doctors and administered a computerized test. Called the Implicit Association Test (IAT), it has been around for a decade, and has been used over 5 million times as a tool to measure implicit biases, as opposed to outright prejudice. In this case, the test subjects were shown pictures of black or white patients. They were asked about the person's attitude ("good" vs. "bad"), as well as their impressions of the person's general cooperativeness and medical cooperativeness.

Along with the photos, they were given a scenario in which the patient exhibited symptoms and a test result suggesting they were having a heart attack. Doctors were asked whether they thought the patient was having a heart attack and whether they would treat him with a thrombolytic drug, a medicine meant to break up a blood clot in the coronary arteries, which is a standard treatment for heart attack victims. Finally, physicians were asked questions that measured whether they harbored any explicit biases toward blacks.

It turns out the doctors didn't harbor any overt bias or prejudice. But the results of the IAT and the outcome of the heart attack scenario told us something quite different: More doctors subconsciously attributed negative traits to blacks (thinking them "uncooperative" or "bad") than whites. Worse was the way these biases translated into clinical decisions. While doctors diagnosed more blacks with a heart attack, they ended up prescribing treatment for blacks and whites in essentially equal numbers, meaning that black patients having heart attacks were going untreated. Further, as the degree of bias toward blacks increased, so did their likelihood of not getting treated.

This study, published last summer in the Journal of General Internal Medicine, was the first hard evidence that doctors' clinical decision making is influenced by race, and that those decisions stand to do harm.

Does this mean that doctors are racist? No. In fact, the discrepancy between explicit and implicit biases in the Harvard study suggests the opposite. But it's clear deeper biases exist, and for several reasons.

Next page: Doctors learn to think in terms of stereotypes